Shoulder Dystocia: Managing an Obstetric Emergency

 

Am Fam Physician. 2020 Jul 15;102(2):84-90.

Author disclosure: No relevant financial affiliations.

Shoulder dystocia is an obstetric emergency in which normal traction on the fetal head does not lead to delivery of the shoulders. This can cause neonatal brachial plexus injuries, hypoxia, and maternal trauma, including damage to the bladder, anal sphincter, and rectum, and postpartum hemorrhage. Although fetal macrosomia, prior shoulder dystocia, and preexisting or gestational diabetes mellitus increases the risk of shoulder dystocia, most cases occur without warning. Labor and delivery teams should always be prepared to recognize and treat this emergency. Training and simulation exercises improve physician and team performance when shoulder dystocia occurs. Unequivocally announcing that dystocia is happening, summoning extra assistance, keeping track of the time from delivery of the head to full delivery of the neonate, and communicating with the patient and health care team are helpful. Calm and thoughtful use of release maneuvers such as knee to chest (McRoberts maneuver), suprapubic pressure, posterior arm or shoulder delivery, and internal rotational maneuvers will almost always result in successful delivery. When these are unsuccessful, additional maneuvers, including intentional clavicular fracture or cephalic replacement, may lead to delivery. Each institution should consider the length of time it will take to prepare the operating room for general inhalational anesthesia and abdominal rescue and practice this during simulation exercises.

Shoulder dystocia is an obstetric emergency in which gentle downward traction of the fetal head does not lead to delivery and additional maneuvers are required to deliver the fetal shoulders.1 Shoulder dystocia is usually attributed to impaction of the anterior shoulder against the maternal symphysis after delivery of the fetal head; less commonly, it is caused by impaction of the posterior shoulder against the sacral promontory.2

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Conduct team training simulation drills that include identification to improve performance during actual shoulder dystocia emergencies.18

B

Longitudinal study of a mandatory shoulder dystocia training program

Announce unequivocally that there is a shoulder dystocia when it occurs.18

B

Longitudinal study of a mandatory shoulder dystocia training program

Elevate both knees to the chest (McRoberts maneuver) as the first therapeutic maneuver during shoulder dystocia.10

B

Retrospective analysis of shoulder dystocia cases

Consider posterior arm delivery if McRoberts maneuver and suprapubic pressure are unsuccessful.10,14,21

C

Clinical guidelines based on consensus, computer modeling, and a retrospective analysis of shoulder dystocia cases

Document precisely the head-to-body delivery interval and maneuvers performed after every shoulder dystocia.10

C

Consensus-based clinical guidelines


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Conduct team training simulation drills that include identification to improve performance during actual shoulder dystocia emergencies.18

B

Longitudinal study of a mandatory shoulder dystocia training program

Announce unequivocally that there is a shoulder dystocia when it occurs.18

B

Longitudinal study of a mandatory shoulder dystocia training program

Elevate both knees to the chest (McRoberts maneuver) as the first therapeutic maneuver during shoulder dystocia.10

B

Retrospective analysis of shoulder dystocia cases

Consider posterior arm delivery if McRoberts maneuver and suprapubic pressure are unsuccessful.10,14,21

C

Clinical guidelines based on consensus, computer modeling, and a retrospective analysis of shoulder dystocia cases

Document precisely the head-to-body delivery interval and maneuvers performed after every shoulder dystocia.10

C

Consensus-based clinical guidelines


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

Shoulder dystocia complicates 0.3% to 3% of all vaginal deliveries.3,4 The exact incidence can be difficult to determine because the diagnosis is subjective and there are no agreed upon diagnostic criteria for shoulder dystocia. Objective criteria of a head-to-body delivery interval of 60 seconds or the need for additional delivery maneuvers are proposed based on the incidence of significantly more birth injuries and lower Apgar scores during these deliveries.5

Risk Factors

The Authors

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D. ASHLEY HILL, MD, is the chair of the Department of Obstetrics and Gynecology at the AdventHealth Graduate Medical Education Program, Orlando, Fla.; a professor of obstetrics and gynecology at the University of Central Florida College of Medicine, Orlando; and the medical director of the Multiprofessional Obstetrics Simulation Training (M.O.S.T.®) program at AdventHealth Orlando....

JORGE LENSE, MD, is the medical director of the Advent-Health Obstetric Hospitalists at the AdventHealth Altamonte, Celebration, Orlando (Fla.) and Winter Park Hospitals and AdventHealth Gynecology Hospitalists at AdventHealth Orlando Hospital.

FAY ROEPCKE, MD, MPH, is a fellow at the Women's Health Junior Faculty Fellowship at AdventHealth Orlando Family Medicine Residency and is an Advanced Life Support in Obstetrics (ALSO) course instructor.

Address correspondence to D. Ashley Hill, MD, 235 East Princeton St., Ste. 200, Orlando, FL 32804 (email: D.Hill.MD@AdventHealth.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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show all references

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